Senior Care Coordinator - Community Prevention and Treatment Services (Req 101094)

GENERAL

RESPONSIBILITIES:

• The Senior Care Coordinator is responsible for the performance of specialty retention and adherence specific care coordination services.
• Central to this role, is the conduct of comprehensive screenings/assessments and enhanced service planning aimed to improve the health and well-being of people living with HIV/AIDS (PLWHA).
• Designed to reduce viral load while supporting PLWHA to independently manage their health care.
• While addressing the medical, behavioral health, community services and social determinants of health for program participants with the highest needs-those newly diagnosed with HIV, starting antiretroviral medications for the first time and/or displaying difficulty adhering to the program due to life events/barriers to care.
• The Senior Care Coordinator serves as a member of the multi-disciplinary team- assisting in the training of the care managers, linkage and peer support staff while maintaining relationships with outside community based agencies.
• SPECIFIC

RESPONSIBILITIES:

• Manages oversight for care coordination activities for specialty retention and adherence specific caseload Conducts outreach and engagement for assigned program participants Develops enhanced service plans to address the medical, mental health, substance use and social services needs for program participants.
• Maintains assigned caseload of patients in all phases of case management and maintains a productivity rate as established by Supervisor Assists patients to achieve outcomes as required by NYSDOH, The AIDS Institute and other regulatory bodies Provides training to staff to ensure that they have full knowledge of the functions of their position(s).
• Identifies and maintains relationships with community based organizations for referrals and linkages.
• Conducts outreach, education and consultation to community based organizations about the services provided to foster strong relationships.
• Enters data accurately on the web-based reporting system(s) and electronic medical record Assists Data analyst and Program Manager with monthly reports as well as yearly reports as needed.
• Monitors patients treatment and medication adherent as well authorizations for medications Ensures that all documentation is completed that meet regulatory, funding and agency requirements including assessments; notes; care/service/treatment plans; Conducts face-to-face Intakes And assessments in the community on program site or at home visits.
• Demonstrates knowledge of development across the lifespan, cultural and linguistic norms of minority populations and subpopulations, and awareness of socioeconomic health disparities as it pertains to medical, mental health, and substance use treatment.
• Provides education, encourages retention in care, adherence to medical treatment, and strategies for promoting chronic disease self-management.
• Manages referrals to appropriate agencies required to assist the client in achieving the goals and objectives identified in the Care/Treatment/Service Plan.
• Participates in multidisciplinary team meetings, case conferences and any service planning meetings to ensure patients are receiving the best care possible Assists clients to access programs that will help pay for medical care and prescriptions.
• Oversees transfers, inactivation, and discharge processes.
• Ensures timely documentation in the electronic health record and in designated State and/or Federal data management systems.
• Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.
• Demonstrates excellence in both internal and external customer service.
• Understands and effectively communicates HIPAA compliance, corporate compliance and client confidentiality.
• Ensures and/or remains in compliance with local, state, and federal regulation, i.e.
• NCQA, Joint commission, NYS Department of Health, HRSA Adheres to the National Patient Safety Goals as defined by NCQA and the Whitney M.
• Young Jr.
• Health Services.
• Completes other duties as assigned.